Ordeal mechanisms, information, and the cost-effectiveness of strategies to provide subsidized eyeglasses.

The cost-effectiveness of policies providing subsidized health goods is often compromised by limited use of the goods provided. Through a randomized trial involving 251 primary schools in western China, we tested two approaches to improve the cost-effectiveness of a program distributing free eyeglasses to myopic children. Relative to delivery of free eyeglasses to schools, we find that providing vouchers redeemable in local optical shops modestly improved the targeting of eyeglasses to those who would use them without reducing effective coverage. Information provided through a health education campaign increased eyeglass use when eyeglasses were delivered to schools, but had no effect when requiring voucher redemption or when families were only given a prescription for eyeglasses to be purchased on the market. Though most expensive, free delivery to schools with a health education campaign was the most socially cost-effective approach tested and increased effective coverage of eyeglasses by 18.5 percentage points after seven months.

Conditional cash transfers, uptake of maternal and child health services, and health outcomes in western rural China.

BACKGROUND: Empirical evidence suggests that the uptake of maternal and child health (MCH) services is still low in poor rural areas of China. There is concern that this low uptake may detrimentally affect child health outcomes. Previous studies have not yet identified the exact nature of the impact that a conditional cash transfer (CCT) has on the uptake of MCH services and, ultimately, on child health outcomes. The objective of this study is to examine the relationship between CCT, uptake of MCH services, and health outcomes among children in poor rural areas of western China. METHODS: We designated two different sets of villages and households that were used as comparisons against which outcomes of the treated households could be assessed. In 2014, we conducted a large-scale survey of 1522 households in 75 villages (including 25 treatment and 50 comparison) from nine nationally designated poverty counties in two provinces of China. In each village, 21 households were selected based on their eligibility status for the CCT program. Difference-in-difference analyses were used to assess the impact of CCT on outcomes in terms of both intention-to-treat (ITT) and average-treatment-effects-on-the-treated (ATT). RESULTS: Overall, the uptake of MCH services in the sample households were low, especially in terms of postpartum care visits, early breastfeeding, exclusive breastfeeding, and physical examination of the baby. The uptake of the seven types of MCH services in the CCT treatment villages were significantly higher than that in the comparison villages. The results from both the ITT and ATT analyses showed that the CCT program had a positive, although small, impact on the uptake of MCH services and the knowledge of mothers of MCH health issues. Nonetheless, the CCT program had no noticeable effect on child health outcomes. CONCLUSIONS: The CCT program generated modest improvements in the uptake of MCH services and mothers' knowledge of MCH services in poor rural areas of Western China. These improvements, however, did not translate into substantial improvements in child health outcomes for two potential reasons: poor CCT implementation and the low quality of rural health facilities.

Parental Migration and Early Childhood Development in Rural China.

Nearly one-quarter of all children under age 2 in China are left behind in the countryside as parents migrate to urban areas for work. We use a four-wave longitudinal survey following young children from 6 to 30 months of age to provide first evidence on the effects of parental migration on development, health, and nutritional outcomes in the critical first stages of life. We find that maternal migration has a negative effect on cognitive development: migration before children reach 12 months of age reduces cognitive development by 0.3 standard deviations at age 2. Possible mechanisms include reduced dietary diversity and engagement in stimulating activities, both known to be causally associated with skill development in early life. We find no effects on other dimensions of physical and social-emotional health.

Breastfeeding and the Risk of Illness among Young Children in Rural China.

Poor rural areas in China exhibit the country's highest rates of child mortality, often stemming from preventable health conditions such as diarrhea and respiratory infection. In this study, we investigate the association between breastfeeding and disease among children aged 6⁻24 months in poor rural counties in China. To do this, we conducted a longitudinal, quantitative analysis of socioeconomic demographics, health outcomes, and breastfeeding practices for 1802 child⁻caregiver dyads across 11 nationally designated poverty counties in southern Shaanxi Province in 2013⁻2014. We found low rates of continued breastfeeding that decreased as children developed: from 58.2% at 6⁻12 months, to 21.6% at 12⁻18 months, and finally to 5.2% at 18⁻24 months. These suboptimal rates are lower than all but one other country in the Asia-Pacific region. We further found that only 18.3% of children 6⁻12 months old met the World Health Organization (WHO)-recommended threshold for minimum dietary diversity, defined as consuming four or more of seven specific food groups. Breastfeeding was strongly associated with lower rates of both diarrhea and cough in bivariate and multivariate analyses. As the first analysis to use longitudinal data to examine the relationship between continued breastfeeding and child illness in China, our study confirms the need for programmatic interventions that promote continued breastfeeding in order to improve toddler health in the region.

The cost-effectiveness of alternative vision screening models among preschool children in rural China.

PURPOSE: To explore the accuracy and cost-effectiveness of three vision screening models among preschool children in rural China. METHODS: Vision screening was carried out among children aged 4-5 years in 65 preschools in two counties in Northwest China, using Crowded Single Lea Symbols to test visual acuity. Children were assigned randomly by school to one of three screening models: screening by teachers (15 schools, 1835 children), local optometrists (30 schools, 1718 children) or volunteers (20 schools, 2183 children). Children identifying ≥2 symbols incorrectly in either eye failed screening. Accuracy of screening was compared with screenings executed by experienced optometrists among 141 children selected randomly from the three screening models. Direct and indirect costs for each model were assessed. Costs to detect a true case failed screening were estimated. RESULTS: The sensitivity for three models ranged from 76.9% to 87.5%, specificity from 84.9% to 86.7% and standardized positive predictive value from 83.7% to 85.7%. None differed significantly between models. The costs per case detected were $37.53, $59.14 and $52.19 for the teachers, local optometrists and volunteers. In producing the cost estimates for teacher screening and local optometrist screening models, we used a salary payment that was identical for both models (with the salary being equal to that of the optometrist). The teacher screening model was the most cost-effective. CONCLUSION: Accuracy of screening by teachers, local optometrists and volunteers was the same in this setting, but the use of teachers was most cost-effective, reducing the cost per case detected by almost 40%.

The gender gap among school children in poor rural areas of western China: evidence from a multi-province dataset.

BACKGROUND: The gender gap remains a major impediment in the path towards equality and it is especially wide in low-income countries. Up to the early 2000s, many studies documented extensive inequalities in China: girls had poorer health, less nutrition and less education than their male counterparts. The goal of this study is to examine whether the gender gap persists, given that China is now making the transition into the ranks of upper-middle income countries. We consider educational outcomes, mental and physical health status, as well as non-cognitive outcomes. METHODS: We draw on a dataset containing 69,565 observations constructed by combining data from 7 different school-level surveys spanning 5 provinces. The surveys were all conducted by the authors between 2008 and 2013 using uniform survey instruments and data collection protocols in randomly selected schools across western provinces in rural China. The sample children range in age from 9 to 14 years (with 79 % of the sample being aged 10 to 12). Our analysis compares rural girls with rural boys in terms of 13 different indicators. RESULTS: With the exception of anemia rates, the health outcomes of girls are equal to those of boys. Girls and boys are statistically identical in terms of weight-for-age, height-for-age, and prevalence of intestinal worm infections. Girls performed better than boys on five of six cognitive and educational performance indicators. Girls performed worse than boys on all mental health indicators. All estimates are robust to the inclusion of different age ranges, controlling for the level of household assets, ethnic minority status, as well as the addition of provincial dummies. CONCLUSIONS: Our findings suggest that with the exception of non-cognitive outcomes, anemia and standardized math test scores, the gender gap in our study areas in China appears to be diminishing.

Survey using incognito standardized patients shows poor quality care in China's rural clinics.

Over the past decade, China has implemented reforms designed to expand access to health care in rural areas. Little objective evidence exists, however, on the quality of that care. This study reports results from a standardized patient study designed to assess the quality of care delivered by village clinicians in rural China. To measure quality, we recruited individuals from the local community to serve as undercover patients and trained them to present consistent symptoms of two common illnesses (dysentery and angina). Based on 82 covert interactions between the standardized patients and local clinicians, we find that the quality of care is low as measured by adherence to clinical checklists and the rates of correct diagnoses and treatments. Further analysis suggests that quality is most strongly correlated with provider qualifications. Our results highlight the need for policy action to address the low quality of care delivered by grassroots providers.

AN INVESTIGATION OF VISION PROBLEMS AND THE VISION CARE SYSTEM IN RURAL CHINA.

This paper examines the prevalence of vision problems and the accessibility to and quality of vision care in rural China. We obtained data from 4 sources: 1) the National Rural Vision Care Survey; 2) the Private Optometrists Survey; 3) the County Hospital Eye Care Survey; and 4) the Rural School Vision Care Survey. The data from each of the surveys were collected by the authors during 2012. Thirty-three percent of the rural population surveyed self-reported vision problems. Twenty-two percent of subjects surveyed had ever had a vision exam. Among those who self-reported having vision problems, 34% did not wear eyeglasses. Fifty-four percent of those with vision problems who had eyeglasses did not have a vision exam prior to receiving glasses. However, having a vision exam did not always guarantee access to quality vision care. Four channels of vision care service were assessed. The school vision examination program did not increase the usage rate of eyeglasses. Each county-hospital was staffed with three eye-doctors having one year of education beyond high school, serving more than 400,000 residents. Private optometrists often had low levels of education and professional certification. In conclusion, our findings shows that the vision care system in rural China is inadequate and ineffective in meeting the needs of the rural population sampled.

Effectiveness of provider incentives for anaemia reduction in rural China: a cluster randomised trial.

OBJECTIVES: To test the impact of provider performance pay for anaemia reduction in rural China. DESIGN: A cluster randomised trial of information, subsidies, and incentives for school principals to reduce anaemia among their students. Enumerators and study participants were not informed of study arm assignment. SETTING: 72 randomly selected rural primary schools across northwest China. PARTICIPANTS: 3553 fourth and fifth grade students aged 9-11 years. All fourth and fifth grade students in sample schools participated in the study. INTERVENTIONS: Sample schools were randomly assigned to a control group, with no intervention, or one of three treatment arms: (a) an information arm, in which principals received information about anaemia; (b) a subsidy arm, in which principals received information and unconditional subsidies; and (c) an incentive arm, in which principals received information, subsidies, and financial incentives for reducing anaemia among students. Twenty seven schools were assigned to the control arm (1816 students at baseline, 1623 at end point), 15 were assigned to the information arm (659 students at baseline, 596 at end point), 15 to the subsidy arm (726 students at baseline, 667 at end point), and 15 to the incentive arm (743 students at baseline, 667 at end point). MAIN OUTCOME MEASURES: Student haemoglobin concentrations. RESULTS: Mean student haemoglobin concentration rose by 1.5 g/L (95% CI -1.1 to 4.1) in information schools, 0.8 g/L (-1.8 to 3.3) in subsidy schools, and 2.4 g/L (0 to 4.9) in incentive schools compared with the control group. This increase in haemoglobin corresponded to a reduction in prevalence of anaemia (Hb <115 g/L) of 24% in incentive schools. Interactions with pre-existing incentives for principals to achieve good academic performance led to substantially larger gains in the information and incentive arms: when combined with incentives for good academic performance, associated effects on student haemoglobin concentration were 9.8 g/L (4.1 to 15.5) larger in information schools and 8.6 g/L (2.1 to 15.1) larger in incentive schools. CONCLUSIONS: Financial incentives for health improvement were modestly effective. Understanding interactions with other motives and pre-existing incentives is critical. TRIAL REGISTRATION NUMBER: ISRCTN76158086.